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Psychological therapies for the management of chronic pain (excluding headache) in adults

  • Review
  • Intervention

Authors


Abstract

Background

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

Objectives

To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

Search methods

We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

Selection criteria

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

Data collection and analysis

Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

Main results

Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

Authors' conclusions

Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Plain language summary

Psychological therapy for adults with longstanding distressing pain and disability

Many people have pain that lasts for a long time, pain that is not relieved by drugs, surgery or physical therapy. The search for a diagnosis and for pain relief is often long, discouraging and even damaging. For some people, the pain leads to disability, depression, anxiety and social isolation. It is also associated with a tendency to experience much or all in life as ruined by pain, as a catastrophe that is impossible to control. These major life changes are not inevitable and are thought to be at least partly reversible using a treatment which aims to reduce disability and distress despite continuing pain. Treatment is based on robust psychological principles that have developed over 40 years of clinical use.

Our search found 42 trials of treatments which met our criteria, but only 35 provided data in a form that could be used. The two main types of psychological treatment are called cognitive behavioural therapy (CBT) and behaviour therapy. Both focus on helping people to change behaviour that maintains or worsens pain, disability, distress and catastrophic thinking; CBT also directly addresses the thoughts and feelings that are a problem for people with persistent pain. The effects of these two treatments on pain, disability, mood and catastrophic thinking were tested immediately after the treatment, and six months later.

Small to moderate benefits, more for disability, mood and catastrophic thinking than for pain, were found in trials which compared CBT with no treatment. Some of these were still positive six months later. Behaviour therapy showed few and only brief benefits. Psychological therapies can help people with chronic pain reduce negative mood (depression and anxiety), disability, catastrophic thinking, and in some cases, pain. Although the overall effect is positive, we do not know enough about exactly which type of treatment is best for which person.

Резюме на простом языке

Психотерапия у взрослых с устойчивой мучительной болью и инвалидностью

Многие люди страдают от устойчивых продолжительных болей, которые не купируются ни лекарствами, ни хирургическими вмешательствами, ни физиотерапией. Процесс постановки диагноза и поиска способа облегчения боли зачастую является долгим, удручающим, и даже повреждающим. У некоторых людей боль приводит к инвалидности, депрессии, тревожности и социальной изоляции. Боль также ассоциируется такими людьми с тенденцией к восприятию всего, что происхит в их жизни, как разрушенное болью, как катастрофа, которую невозможно контролировать. Эти серьезные жизненные изменения отнюдь не неизбежны, и считается, что они по меньшей мере обратимы при лечении, направленном на снижение нетрудоспособности и страданий, несмотря на постоянную боль. Лечение основано на надёжных психологических принципах, разработанных на протяжении более сорока лет клинического применения.

Наш поиск выявил 42 клинических испытания, соответствовавших нашим критериям, однако лишь 35 из них располагали данными в приемлемой форме. Два основных вида психотерапии были: когнитивная поведенческая терапия (КПТ) и поведенческая терапия. Оба вида сосредоточены на оказании помощи людям в изменении поведения, которое поддерживает или усиливает боль, нетрудоспособность, страдания и негативное мышление. КПТ также напрямую обращена на мысли и чувства, которые являются проблемой у людей с устойчивой болью. Влияние этих двух методов лечения на боль, нетрудоспособность, настроение и негативное мышление проверялось сразу после лечения и шесть месяцев спустя.

Испытания, сравнивавшие результаты КПТ с отсутствием лечения, выявляли малое и умеренное благоприятное воздействие, в основном в отношении нетрудоспособности, настроения и негативного мышления, нежели в отношении боли. В некоторых случаях эффект сохранялся по истечении шести месяцев. Поведенческая терапия оказывала незначительное и кратковременное благоприятное воздействие. Психотерапия может помочь людям с хроническими болями уменьшить негативный настрой (депрессию и тревогу), нетрудоспособность и негативное мышление, а в некоторых случаях и боль. Несмотря на то, что общий эффект положителен, нам неизвестно наверняка, какой именно вид лечения подходит конкретному человеку.

Заметки по переводу

Перевод: Бокаева Камила Алгабековна. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Cochrane Russia - Кокрейн Россия (филиал Северного Кокрейновского Центра на базе Казанского федерального университета). По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: lezign@gmail.com

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